Overview
A recent study published in JAMA estimates that more than six million people in the US have diet-sensitive conditions and activity limitations who could benefit from medically tailored meals, a type of medically assisted diet and nutrition (MSF&N). These estimates also suggest that providing such meals to these individuals could prevent 1.6 million hospitalizations and save $13.6 billion annually. In recent years, mounting evidence of the positive effects of nutrition assistance on health outcomes and costs has contributed to policy change at both the federal and state levels – which in turn creates new opportunities for health and nutrition services organizations to work together to improve health improve through the services of Doctors Without Borders. This discussion highlights some of these possibilities.
What are MSF&N services?
MSF&N services represent a spectrum of services that recognize and respond to the critical link between nutrition and health, which may include medically tailored meals and groceries, medically assisted meals and groceries, product prescriptions, and food pharmacies. The Food is Medicine Coalition, a national group of nonprofit MSF&N providers, depicts these services along a spectrum that corresponds to the severity of the individual’s need. (See Figure 1.)
Figure 1. Spectrum of food and nutrition interventions to improve health
Source: Food Is Medicine Coalition: Our Model
By definition, MSF services are integrated into patient-centered care models for the prevention, management and treatment of chronic diseases and health conditions, and are distinct from the broader hunger safety net (e.g. the Supplemental Nutrition Assistance Program or the National School Lunch Program).
Recent changes in health care policy to support Doctors Without Borders services
As the evidence base supporting the value of MSF services to health outcomes and costs has grown, new pathways to authority, financing and integration into the health care system have emerged.
Medicaid and the Children’s Health Insurance Program (CHIP): Historically, certain MSF&N services were typically only available as part of Medicaid Home and Community Based Services (HCBS) programs for individuals receiving long-term support services. In the 2010s, California, Massachusetts, and North Carolina became the first states to use Medicaid Section 1115 demonstration waivers to pay for MSF&N for individuals with certain complex chronic diseases and other health conditions. Since then, several other states have followed suit by using 1115 waivers or under Medicaid managed care “in lieu of services” (ILOS) authorities to fund MSF&N services in their Medicaid programs.1
In 2022, the Centers for Medicare and Medicaid Services (CMS) began formalizing its policy on Doctors Without Borders, in addition to that on housing, culminating in a November 2023 Information Bulletin and associated framework, which includes the following Approved services related to food and nutrition are listed:
- Case management services for food/nutrition access;
- Nutritional advice and instruction;
- Meals delivered to your home or stockpile;2
- Dietary guidelines (e.g. vegetable and fruit recipes or protein boxes); And
- Grocery supply.
CMS’s guidance goes beyond Section 1115 waivers and outlines other options for MSF’s Medicaid coverage, including options for covering such services through managed care plans (under ILOS authority), for populations requiring long-term services and supports (through HCBS waivers), as part of the regular package of Medicaid benefits (through state plan amendments), and for children (through CHIP Health Services Initiatives).
Medicare: In 2020, CMS issued guidance to further define and expand the special chronically ill supplemental benefits (SSBCI) that Medicare Advantage plans, including Dual Eligible Special Needs Plans (D-SNPs), can offer to improve health outcomes for chronically ill enrollees. Medicare Advantage plans can use SSBCI to provide meals, food, produce, and grocery transportation. According to an analysis by Milliman, food, produce, and meal assistance were among the most common SSBCI benefits offered by Medicare Advantage plans in 2023. Medicare Part A (traditional fee-for-service Medicare) does not currently cover home-delivered meals or other Doctors Without Borders services.
Commercial and marketplace programs: The Biden administration has sought to prioritize the integration of nutrition into the delivery of health care for all payers. Commercial or marketplace plans make medically tailored meals and/or grocery delivery available to enrollees with specific diet-related health concerns nationwide. For example, Geisinger Health’s Fresh Food Farmacy provides fresh, healthy food every week to enrollees and their families when enrollees have an A1C level above 8.0 and are food insecure. Since its launch in 2016, enrollees participating in the Fresh Food Farmacy program have shown an average decrease of 2 points in HbA1c level, lower weight, blood pressure, triglycerides and cholesterol, and the plan found that medical costs were between $16,000 and $24,000 per participating insured decreased.
Extensive options for MSF&N services
States: CMS’s recent guidance provides a roadmap for states seeking to authorize, design, and launch MSF&N programs in their Medicaid systems. In the several states that have implemented MSF&N services, the Medicaid program has already become one of the largest funders of such services. States play a critical role in defining which MSF&N services are covered, who is eligible to receive them, what standards providers must meet, and what data must be collected to evaluate outcomes. As more states implement MSF&N services through Medicaid and document results and lessons learned, other states will likely follow suit.
Health insurance plans (Medicaid Managed Care Plans, Medicare Advantage, private insurers): Expanded reimbursement for MSF&N services allows plans to invest in popular, cost-effective interventions that can improve outcomes, reduce utilization, and improve the enrollee experience. As more states choose to add coverage for MSF&N to their Medicaid programs, many states are incorporating service charges into plan rates and delegating management of services to plans, including identifying and engaging eligible individuals, contracting with and overseeing MSF&N provider organizations and tracking enrollee utilization and health outcomes. Although commercial market adoption is still in its infancy, robust and thoughtful MSF&N programs can give commercial plans a competitive advantage and help keep costs down.
Healthcare providers: With the expansion of MSF coverage, many healthcare providers are partnering with local food and nutrition organizations to screen, identify and refer patients with chronic diet-related diseases who are food insecure and could benefit from MSF services. As value-based payment arrangements continue to expand, providers who assume financial risk for their patients may see the integration of cost-effective interventions such as MSF services as an attractive offering to support their patients and reduce costs and utilization. push.
MSF&N organizations: As MSF services become more integrated into health care, nutrition organizations have a new opportunity to support and scale their work. For example, the Food is Medicine Coalition has developed a voluntary national accreditation program for MSF providers. Grants and technical assistance (available through Medicaid programs, health plans, and/or philanthropy) can help organizations establish new systems and expanded capabilities, such as contracting, administrative, data, and billing functions, needed to support MSF service delivery. Larger and more experienced MSF organizations may have new opportunities under such programs to train other organizations and be reimbursed for this role. Organizations can also form so-called “Community Care Hubs,” which work together to share administrative functions and operational infrastructure and serve a more diverse range of populations. States vary in the extent to which they encourage such hub formation.
Issues we track
- What are the state’s Medicaid programs like:
- Give permission for the financing of Doctors Without Borders services (for example through exemptions under Article 1115, ILOS, exemptions of the HCBS)?
- Financially incentivizing investments in the Medicaid plan and/or providers in MSF services (e.g., reinvestment requirements, quality measures, incentive schemes)?
- Integrate the cost of MSF services into Medicaid managed care rates?
- How are federal and state policymakers encouraging Medicare Advantage plans and D-SNPs to offer MSF services through SSBCI?
- What support do health insurers and healthcare providers need to effectively integrate MSF&N services into healthcare?
- What infrastructure and capacity challenges do MSF providers face as they begin billing and exchanging data with health care organizations, and how do states, plans, and providers help address these challenges?
- What provider qualification standards and oversight processes do states and plans use for MSF&N services?
- How do states and other payers evaluate the effectiveness of Doctors Without Borders services?
Conclusion
MSF&N services can help improve the lives and health outcomes of millions of Americans with diet-related health conditions. The increasing coverage of MSF&N services, coupled with the growing recognition of food and nutrition as upstream drivers of health outcomes, reflect an encouraging focus on whole-person care.
1 As of April 2024, state Medicaid programs with the authority to pay for MSF services for specific populations include: Oregon, Washington, New Jersey, North Carolina, Massachusetts, New York, and California.
2 Notably, CMS’s framework provides that Section 1115-authorized nutrition assistance programs that provide participants with three meals per day are limited to six months, renewable for additional six-month periods if the participant continues to meet eligibility criteria. This limitation does not apply to programs that provide fewer than three meals per day.